• Alberto Bouzas-Mosquera, Jesús Peteiro, Francisco J Broullón, Nemesio Álvarez-García, Nicolás Maneiro-Melón, Patricia Pardo-Martinez, Marta Sagastagoitia-Fornie, Dolores Martínez, Juan C Yáñez, and José Manuel Vázquez-Rodríguez.
• Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain. Electronic address: alberto.bouzas.mosquera@sergas.es.
• Am J Emerg Med. 2016 Aug 1; 34 (8): 1421-6.

IntroductionAlthough cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting.MethodsA decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary end point was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months.ResultsA score chart was built based on 7 variables: male sex (+2), age (+1 per decade from the fifth decade), diabetes mellitus (+2), hypercholesterolemia (+1), prior coronary revascularization (+2), type of chest pain (typical angina, +5; non-specific chest pain, -3), and non-diagnostic repolarization abnormalities (+2). In the validation set, the model showed good discrimination (c statistic = 0.84; 95% confidence interval, 0.82-0.87) and calibration (Hosmer-Lemeshow goodness-of-fit test, P= .34). If stress tests were avoided in patients in the validation sample with a sum score of 0 or lower, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval, 97.0%-99.7%).ConclusionThis novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins.Copyright © 2016 Elsevier Inc. All rights reserved.

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